Intravenous fluid administration in POTS

Chronic infusion therapy

In this article, chronic infusion therapy (at home) is discussed as a treatment option for POTS.

We will take a moment to discuss IV therapy in POTS as well as the options on how this can be done for both the choice of which type of intravenous line and the frequency of administration.

Chronic infusion therapy at home is not a standard treatment for POTS, nor is it encouraged because of the multiple risks involved.

Contact your treating physician if there are any indications that indicate the need for this!

IV therapy with saline for POTS -

The following criteria may help to consider IV fluid administration regard to POTS:

• Unstable advanced dehydration that cannot be controlled by oral drinking
• Continuous low blood volume that is progressing and cannot be controlled by oral drinking
• Frequent feeling unwell and often fainting, forcing the patient to lie down almost continuously (severe POTS symptoms)
• Heavy deconditioning
• Malnutrition due to other conditions such as gastroparesis or other gastrointestinal disorders involving tube feeding
• Other reasons why there is no other possibility that the necessary moisture and salts can be taken orally

Available options regarding the frequency of intravenous fluid administration:

The physician determines the frequency of the administration once he / she is willing to do or try this and also the duration of this.

Few scientific articles are available that support the positive effect in POTS patients on the administration of fluids intravenously and is mainly based on the positivity about this in POTS patients themselves.

The possible regularity of administrations can vary and depends on the severity of the patient's complaints and his / her personal general medical record (with possibly multiple conditions).

In case of severe complaints such as advanced dehydration, very low blood pressure, chest pain and / or certain concerns about the health condition, it is recommended to go to an emergency room or to contact a doctor as soon as possible!

A single administration in an emergency or hospital of 1 liter of saline can relieve the acute symptoms of POTS.

The physician may decide to hospitalize the POTS patient for a period of time to administer additional fluids intravenously until the symptoms have stabilized and the patient has improved symptomatically.

The doctor may choose to administer fluids in the hospital several times a week via a regular small IV that is placed in the arm. The patient is then administered 1 liter with saline with a run-in time of several hours. This treatment can be paused when the patient is stable with dehydration / blood volume or shows symptomatic stability and has sufficiently recovered. This therapy can be restarted if the patient deteriorates.

The doctor may choose to give infusion therapy of 1 to a maximum of 2 liters of fluid several times a week by means of home placement and calling in home nurses with a follow-up and check-up (regular consultations with blood samples).

Finally, the doctor may also choose to administer fluids to the patient on a daily basis from 1 to a maximum of 2 liters per day via home placement and by calling in home nurses with close monitoring (regular consultations with blood samples). This is an extremely rare method.

What intravenous administration options are there?
There are different types of venous access options:

PICC: a central line that is placed at the bottom of the upper arm and fixated with a statlock. This is a minor procedure with a day hospitalization under local anesthesia. This central line can be removed at any time by a doctor or nurse. This line can remain in place for 6-12 months.

PAC: portal catheter under the collarbone, this is placed under the skin and can remain in place for up to 6-8 years. This is an operation by day hospitalization under general anesthesia. The portal catheter is mainly placed in patients for treatment with chemo.

Hickmann: the same as a PICC line but below the collarbone.

The possible reasons why most doctors don't want to administrate IV therapy:

• The insufficient scientific literature available on POTS and treatment method. POTS syndrome cannot have life-threatening consequences.
  POTS is NOT life threatening if there are NO underlying (heart) conditions! Dehydration and low blood volume (caused by POTS) can lead to a shock state and thus become life-threatening.
• The risks of having a central line such as infection at the insertpoint or sepsis (septicemia) and blood clot formation. The risks of the fluid administration itself, which must always be carefully treated by a nurse, for example air in the line that enters the body can be life-threatening.
• The doctor does not want to run the risk of being initially made for this if one of the above occurs with a condition that is still relatively unknown and also does not fall under the regular treatment in which the protocol of infusion therapy is started.

Available scientific articles for POTS with IV therapy:

These articles contain one and the same statement:

The beneficial effects of IV therapy have not been scientifically proven and are solely based on the positive experiences of the POTS patients, mentioning percentage in a study. Intravenous fluid administration is not included in the literature as a possible treatment method for POTS.

“If nonpharmacologic approaches are not completely effective, pharmacologic therapies may be targeted at specific problems. Patients who are known to or are strongly suspected of having hypovolemia should drink at least 2–3 L of water per day, and dietary salt intake should be increased to approximately 10–12 g/day, if tolerated, using salt tablets, if necessary. Fludrocorti- sone might be useful for boosting sodium retention and expanding the plasma volume, although these pharmacody- namic effects might last only 1–2 days, and its effectiveness has not been tested in randomized clinical trials.Midodrine is metabolized to a peripheral alpha-1 agonist that constricts veins and arteries and might be useful for increasing venous return. Midodrine significantly reduces orthostatic tachycardia but to a lesser degree than intravenous saline. Midodrine has a rapid onset with only brief effects and should be administered 3 times daily. The drug should only be administered during daytime hours as it can cause supine hypertension.
A related strategy is to augment blood volume with intravenous saline. Expert centers report anecdotally that 1 L of normal saline infused over 1 hour decreases orthostatic tachycardia and improves symptoms for several hours to 2 days. Although it has not yet been assessed in a clinical trial, this approach is recommended as rescue therapy for patients who are clinically decompensated and whose symptoms have worsened significantly. This approach could also prevent hospitalizations. Long-term infusions of intra- venous saline are not recommended for routine care, because they usually require the insertion of a chronic central venous catheter, with its attendant complications.”

Source: Sheldon et al HRS Expert Consensus Document on POT/IST/VVS

Study about intravenous saline therpy with patients (+ schedule).
http://standinguptopots.org/resources/iv-saline

Visual methodology 

- Nursing and trading method for IV therapy at home